A rare cause of specific cough in a child: the importance of following-up children with chronic cough
© Barr et al; licensee BioMed Central Ltd. 2005
Received: 13 July 2005
Accepted: 21 September 2005
Published: 21 September 2005
For many years, the term 'specific cough' has been used as a clinical cough descriptor in children to signify the likelihood of an underlying disease causing the cough. In this case study, we describe a child with specific cough caused by a rare carcinoma, a mucoepidermoid carcinoma of the bronchus. The cough only totally resolved after the primary cause was successfully treated. This report highlights the importance of following up children with cough, especially those with specific cough.
An 8-year-old girl from a remote Aboriginal community approximately 2500 km from Brisbane was transferred to our hospital for management of a bronchial lesion. She had received 7-days of intravenous amoxicillin prior to transfer. She had a 4-year history of daily wet and sometimes productive cough, which was worse on exertion. There was no history of exertional dyspnoea, haemoptysis or weight loss. She also had a history of recurrent admissions for pneumonia at the local hospital (3 in the past 6 months). In the child's community, two adults were recently diagnosed with active pulmonary tuberculosis.
We have described a child with several features of chronic specific cough caused by suppurative lung disease secondary to a rare life threatening lesion, a mucoepidermoid carcinoma obstructing a major bronchus. The child's cough only totally resolved upon removal of the tumour; i.e. after the primary cause was successfully treated. This report illustrates the importance of following-up children with chronic cough. Cough was this child's only symptom that was consistently present between the child's recurrent hospitalisations.
Paediatric cough, unlike cough in adults, is generally classified for practical purposes into cough descriptors of 'non-specific' and 'specific' cough [1, 2]. In children with wet cough, airway secretions are always present . Wet cough is a feature of specific cough as children (especially young children), unlike adults, do not often expectorate sputum. Several features of specific cough were present in this child; specifically, daily moist or productive cough, recurrent pneumonia and abnormal auscultatory findings  were present. Thus she had specific cough pointers and, in ideal circumstances, clinicians would be cognisant that the cough is likely associated with an underlying respiratory problem and hence requires further workup and follow-up to define the aetiology. Also, in children, the recommended minimum investigations for any child with a chronic cough are a CXR and spirometry . In this child, the CXR was clearly abnormal – another indicator that further follow-up and investigations are usually required. This child had clinical features of bronchiectasis for at least several months and most likely a few years before eventual diagnosis of the underlying cause of her cough and respiratory illness. Also, radiological evidence of bronchiectasis was present and was secondary to a low-grade MEC that caused obstructive bronchiectasis (hence chronic wet cough from suppurative lung disease) and recurrent pneumonia. Unfortunately, the bronchiectasis was not restricted to the RUL; the delay in diagnosis allowed growth of the tumour that was so large it obstructed the entire right main bronchus and lead to obstructive bronchiectasis of the right lung.
Presentation of patients with MEC is unusual until some obstruction of the involved airway occurs [6–9]. Common presenting symptoms include cough, recurrent pneumonia, haemoptysis, wheeze, dyspnoea, fever, and chest pain [7, 8, 13]. The rarity of these tumours contributes to delays in diagnosis [7, 8]. While a diagnostic delay of up to 20-months has been reported , the likely several years interval in this child seemed particularly noteworthy. Deficiencies in health resources available in remote regions are well documented . Indigenous Australians comprise a significant subset of this population and are particularly afflicted by respiratory illness [15, 16]. As many of the presenting respiratory symptoms have an infective cause, the diagnostic suspicion of carcinoma in this setting is potentially further reduced. While adverse outcomes may be minimal, delays in diagnosis could lead to increased and prolonged morbidity. This report highlights the need to clinically follow-up all children with chronic cough especially those with chronic specific cough. After successful treatment of the underlying cause, cough almost always resolves in children. In patients with chronic specific cough and/or other respiratory symptoms not responsive to standard medical therapy, further investigations that include radiology and, in selected children, bronchoscopy should be promptly initiated .
The authors are grateful to Dr. Peter Borzi and Dr. Morgan Windsor who expertly performed the lobectomy. We also thank Barry Dean who provided the digital images.
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